Access this article online Annals of African Medicine Vol. 10, No. 1; 2011:59-63 Quick Response Code: Website: www.annalsafrmed.org PMID: Case Report ***** DOI: 10.4103/1596-3519.76592 Severe pentasomide Armillifer armillatus infestation complicated by hepatic encephalopathy Page | 59 Ademola A. Adeyekun, Ikechukwu Ukadike, Victor A. Adetiloye1 Department of Radiology, University of Benin Teaching Hospital, PMB 1111 Benin City, 1Department of Radiodiagnosis, Obafemi Awolowo University Teaching Hospital PMB 1153 Ile-Ife, Nigeria Correspondence to: Dr. Ademola A. Adeyekun, Department of Radiology, University of Benin Teaching Hospital, PMB 1111 Benin City, Nigeria. E-mail: [email protected] Abstract Background: Diagnosis of Armillifer armillatus infestation is usually incidental, commonly via autopsy or radiography. Affected individual are usually asymptomatic. The case presented here, however, had severe thoracic and abdominal involvement with clinical manifestations. Aim: To report a case of heavy A. armillatus infestation in an adult female Nigerian rural dweller complicated by hepatic parenchyma damage. Setting: Case report from semi-urban southern Nigeria, using clinical records and imaging findings. Materials and Methods: Clinical case records, including laboratory results and radiographic /computed tomography images. Conclusion: Parenchymal damage with organ dysfunction can be seen with severe A. armillatus infestation. Thus, there is a need for regular health education regarding the risk of A. armillatus infestation for individuals who consume snake meat. Keywords: Armillifer armillatus, hepatic encephalopathy, snake meat consumption Résumé Fond: Diagnostic de Armillifer armillatus infestation est généralement accessoire, généralement via l'autopsie ou de radiographie. Personne sont habituellement asymptomatique. Le cas présenté ici, cependant, avaient atteinte grave, thoracique et abdominal, avec les manifestations cliniques. But: Pour signaler un cas de lourds, une infestation d'armillatus dans un océan rural nigérian femelle adulte compliquée par le parenchyme hépatique dommages. Paramètre: Rapport de la cas de semi-urbaines sud du Nigeria, à l'aide de dossiers cliniques et l'imagerie des conclusions. Méthodes et matériaux: Dossiers cliniques, y compris les résultats de laboratoire et des images de tomographie radiographique / calculée. Conclusion: Parenchymal dommages avec un dysfonctionnement organique peuvent être vus avec grave une infestation d'armillatus. Ainsi, il est nécessaire pour l'éducation en santé régulières concernant le risque d'une infestation d'armillatus pour les personnes qui consomment de la viande de serpent. Mots clés: Armillifer armillatus, encéphalopathie Introduction Armillifer armillatus is a type of worm belonging to the hépatique, la consommation de viande de serpent phylum Pentastomida. Pentastomiasis, also known Annals of African Medicine Vol. 10, January-March, 2011 Adeyekun, et al.: Heavy Armillifer armilatus infestation as porocephalosis or tongue worm infestation, is a range 5.5–6.9 mg/dl), albumin was low at 2.2 mg/ rare infection that is generally limited to the tropics dl (normal 3.5–5.0 mg/dl). The urea level was 6.1 and subtropics. The worm normally inhabits the mg/dl (normal 10–50 mg/dl). The hemoglobin respiratory tract of snakes and reptiles and only level was low (9.2 g/dl). Hepatitis B surface antigen occasionally infects humans. (HbsAg) was negative. She did not give consent for liver biopsy. The radiological literature on pentastomiasis is sparse. Linguatula serrata and A. armillatus account Chest x-ray revealed multiple crescentic, comma- for more than 99% of all reported human cases.[1] shaped, calcific opacities distributed in both When the parasite load is low, the overwhelming hemithoraces [Figure 1], with marked concentration Page | 60 majority of cases are asymptomatic and are generally of these opacities in the right hemidiaphragmatic discovered only incidentally during autopsy, routine region. A diagnosis of A. armillatus parasitic x-ray examination, or surgery. infestation was made based on the typical shape of the opacities. On further questioning, the patient A case of heavy A. armillatus infestation with confirmed that snake meat had been a regular part of derangement of hepatic function is presented in this her diet for many years and that she always prepared article; we report this case because of the unusual the meat herself. presentation. A thoraco abdominal CT scan was done subsequently. Case Report The scanogram showed multiple crescentic, comma- shaped, calcific densities distributed over the entire A 57-year-old farmer, was referred to the medical outpatient department with a 6-month history of mood disturbance, occasional confusional state, depression, pruritus, and altered sleep pattern. The pruritus was more pronounced at night. Her past medical history revealed that she had been treated 1 on several occasions for pneumonia. About 2 /2 years earlier she had been treated for pulmonary tuberculosis at a peripheral hospital. She had had several episodes of upper abdominal pain associated with vomiting and the passage of watery stool, but these attacks had all been managed conservatively. There was no previous history of blood transfusion or regular usage of sharp objects like piercing needles. There was associated weight loss. On examination, she looked chronically ill and was emaciated. She was pale and mildly icteric, but was Figure 1: Posteroanterior chest radiograph with bilateral, multiple, not dehydrated. There was finger clubbing. The crescentic calcific densities of dead armillifer larvae. other positive findings included a musty breath odor, mild flapping tremor (mild asterixis), and features of muscle rigidity. The chest, abdominal, and cardiovascular examinations were all normal. Her blood pressure was 130/90 and her pulse rate was 92 beats per minute. A working diagnosis of possible grade 1 hepatic encephalopathy, secondary to chronic liver disease, was made and radiological and laboratory investigations were requested. Among the laboratory investigations, liver function test revealed increased alkaline phosphatase (ALP) of 55 U/l (normal 5–35 U/l). The enzymes GGT and 5′-nucleotidase were not assayed because of lack of facilities. The serum total bilirubin was 2.3 mg/dl (normal 0.5–1.5 mg/dl) and conjugated bilirubin was 1.2 mg/dl (normal <0.05 mg/dl). The Figure 2: Abdominal CT-scannogram showing the numerous serum total protein was low at 5.0 mg/dl (normal crescentic calcific densities, especially over the hepatic region. Vol. 10, January-March, 2011 Annals of African Medicine Adeyekun, et al.: Heavy Armillifer armilatus infestation abdomen, with predominance in the hepatic Discussion region [Figure 2]. Transverse non-enhanced slices showed overwhelming hepatic involvement by the The first human infection by a pentastomid was calcific deposits, with gross distortion of the liver described by Prunner in Cairo in 1847.[2] Two parenchyma [Figure 3]. The deposits were also species, A. armillatus and Linguatula serrata, account concentrated in the spleen. The bowels, mesentery, for more than 99% of all reported human cases.[1] and the urinary bladder were also affected [Figure Among the four species of Armillifer, armillatus 4]. A radiologic diagnosis of severe A. armillatus is found most commonly in West Africa, where infestation with liver parenchyma involvement was the infection rate may be as high as 23% and the [3] made. radiological incidence about 1.4%. Infestation Page | 61 by A. armillatus was diagnosed radiologically in this She was managed as a case of grade 1 hepatic woman. The other species of Armillifer which can encephalopathy secondary to severe liver also be recognized radiologically is A. monniliformis, parenchymal parasitic infestation. She was placed which causes porocephalosis. It is not common in on a high-carbohydrate, low-protein diet and treated West Africa but is found in South and East Asia. with antibiotic (metronidazole), antihistamines, Prathap et al. found a 45% incidence during autopsies and lactulose. in Malaysian aborigines.[4] This disease is commoner in males than in females as documented by Nzeh et On follow-up 3 weeks later at the outpatient clinic al.,[5] with a male: female ratio of 2:1. Our patient she showed significant clinical improvment. too was a female. Infection with pentastomids is mostly asymptomatic in humans, being especially seen in those who regularly consume snake meat. Our patient admitted to having regularly eaten snake meat for several years. The larvae usually die and calcify within 2 years of infection of a human host.[6] However, pentastomids have the potential to cause harm, and, in rare cases, even to cause medical emergencies.[7] In heavy infestation, as in this case, the migration of many live larvae beneath the peritoneum or pleura may cause sufficient irritation to mimic an acute abdominal condition or pleurisy.[7] The encysted larvae can cause abdominal pain, vomiting, constipation, and diarrhea. The presence of extremely high numbers of cysts in some locations can even cause death. Figure 3: Non-enhanced axial CT-slice of the upper abdomen [8] showing concentration of the calcific deposits in the liver, with Pneumonitis, bronchitis, pleuritis, pericarditis, parenchymal distortion. hepatitis, and peritonitis, have all been noted in patients with severe infection.[3] Our patient, according to her past medical history, had been treated several times for pneumonitis